| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
214 |
203 |
$18K |
| D1120 |
Prophylaxis - child |
133 |
133 |
$12K |
| D1110 |
Prophylaxis - adult |
143 |
143 |
$9K |
| D0330 |
Panoramic radiographic image |
56 |
56 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
113 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
209 |
208 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
286 |
284 |
$656.27 |
| D0220 |
Intraoral - periapical first radiographic image |
466 |
451 |
$379.22 |
| D0230 |
Intraoral - periapical each additional radiographic image |
533 |
360 |
$217.29 |
| D1206 |
Topical application of fluoride varnish |
159 |
159 |
$0.00 |